Elderly – State of Healthhttps://ww2.kqed.org/stateofhealth
KQED Public Media for Northern CAThu, 17 Aug 2017 07:31:26 +0000en-UShourly1https://wordpress.org/?v=4.2.290498487Hospital Companions Can Ease Isolation For Older Peoplehttps://ww2.kqed.org/stateofhealth/2016/11/21/hospital-companions-can-ease-isolation-for-older-people/
Mon, 21 Nov 2016 20:10:35 +0000http://ww2.kqed.org/stateofhealth/?p=262090Loneliness can be a problem for older people, especially when they’re in the hospital. Their children may have moved away. Spouses and friends may themselves be too frail to visit. So a California hospital is providing volunteer companions in the geriatric unit.

One of the volunteers at the UCLA Medical Center in Santa Monica is 24-year-old Julia Torrano. She hopes to go to medical school. Meanwhile, her twice-weekly volunteer shifts give her a lot of practice working with patients.

One of them is Estelle Day. She’s 79 years old, a slender woman with a wild mane of hair that is still mostly red. Torrano peppers her with questions.

“Where were you originally from?” asks Torrano. Day replies that she grew up on Long Island in New York. Torrano also wants to know how Day met her husband, where she learned to play the harp, where her travels have taken her.

Day is happy to answer everything. She says she likes people and describes herself as “windbaggy.” That’s especially true if she’s talking about playing music. She is a lifelong musician and retired music teacher. She plays harp and guitar, but her favorite instrument is the pipe organ. “To be able to rock a building under your hands and your feet is exciting,” she says.

This was Day’s fifth day as a patient in the geriatric unit. She says multiple chronic conditions brought her here, but she didn’t want to name them. Visible were a bulky back brace she wears for her osteoporosis, an IV drip and a heart monitor.

When that heart monitor suddenly began beeping, Torrano was out of the room like a shot. She returned seconds later with a nurse who solved the problem with the push of a button.

Torrano and the other volunteer companions aren’t just candy stripers, bringing snacks and magazines. She knew what to do when the heart monitor started beeping because, like all of the volunteers in this program, she’s been trained. As Dr. David Reuben, chief of geriatrics at the Geffen School of Medicine at UCLA explains: “Just because you’re willing to do something doesn’t mean you know how to do it.”

Volunteers learn about medical confidentiality, what to do in an emergency, and how to interact with patients, including patients with dementia. Reuben says they go through a “vigorous training process and vetting process before we allow them to be with patients.” There are nearly three dozen volunteers so far. The program started just a few months ago, and the hospital plans to expand it.

Loneliness is a legitimate medical issue. There are a number of studies linking loneliness and social isolation in old people to poorer health and earlier death, including one published earlier this month in JAMA Psychiatry associating loneliness, social isolation and brain changes typical in Alzheimer’s. Reuben cautions that those studies weren’t done in a hospital setting. Nevertheless, he says, “you might suspect that being more engaged, more energized … might promote a speedier recovery.”

So now the hospital is designing studies to find out if the volunteer companionship improves medical outcomes, or at least improves the patient’s experience in the hospital.

Torrano says she’ll sometimes spend her entire four-hour shift with a single patient. Like Estelle Day, many are happy to share their life stories. She remembers one man in particular who had been a political prisoner in Iran. He’d run an underground newspaper. “He was in jail so much,” she recalls, yet he told her he also misses Iran. “Even though it was very traumatic, he still wishes he was there,” Torrano says.

Estelle Day says she’s not especially lonely, but she has been alone much of the time since she was admitted to the geriatric unit. So it helps to have a companion who will not only listen to her life story, but can also troubleshoot the little problems that can make life in a hospital such a challenge. “Somebody who is sensitive and tuned-in and is very helpful,” explains Day, the way Torrano was when Day’s heart monitor started acting up.

And companionship can take many forms. On the day of Torrano’s visit, one of Day’s most pressing issues was fixing her hair. It had been shoved up in a rubber band since she was admitted.

So with Day’s encouragement, Torrano picks up a comb and gently begins detangling. Whatever it takes to make the patient look good and feel better.

]]>262090Worries as the For-Profit World Moves into Elder Carehttps://ww2.kqed.org/stateofhealth/2016/08/24/worries-as-the-for-profit-world-moves-into-elder-care/
https://ww2.kqed.org/stateofhealth/2016/08/24/worries-as-the-for-profit-world-moves-into-elder-care/#respondWed, 24 Aug 2016 21:30:33 +0000http://ww2.kqed.org/stateofhealth/?p=228587DENVER — Inside a senior center here, nestled along a bustling commercial strip, Vivian Malveaux scans her bingo card for a winning number. Her 81-year-old eyes are warm, lively and occasionally set adrift by the dementia plundering her mind.

Dozens of elderly men and women — some in wheelchairs, others whose hands tremble involuntarily — gather excitedly around the game tables. After bingo, there is more entertainment and activities: Yahtzee, tile-painting, beading.

But this is no linoleum-floored community center reeking of bleach. Instead, it’s one of eight vanguard centers owned by InnovAge, a company based in Denver with ambitious plans. With the support of private equity money, InnovAge aims to aggressively expand a little-known Medicare program that will pay to keep older and disabled Americans out of nursing homes.

Until recently, only nonprofits were allowed to run programs like these. But a year ago, the government flipped the switch, opening the program to for-profit companies as well, ending one of the last remaining holdouts to commercialism in health care. The hope is that the profit motive will expand the services faster.

Hanging over all the promise, though, is the question of whether for-profit companies are well-suited to this line of work, long the province of nonprofit do-gooders. Critics point out that the business of caring for poor and frail people is marred with abuse. Already, new ideas for lowering the cost of the program have started circulating. In Silicon Valley, for example, some eager entrepreneurs are pushing plans that call for a higher reliance on video calls instead of in-person doctor visits.

An elderly woman pushing her walker. (Sean Gallup/Getty Images)

The business appeal is simple: A baby boom-propelled surge in government health care spending is coming. Medicare enrollment is expected to grow by 30 million people in the next two decades, and many of those people are potential future clients. Adding to the allure are hefty profit margins for programs like these — as high as 15 percent, compared with an average of 2 percent among nursing homes — and geographic monopolies that are all but guaranteed by state Medicaid agencies to ensure the solvency of providers.

The goal of the program, known as PACE, or the Program of All-Inclusive Care for the Elderly, is to help frail, older Americans live longer and more happily in their own homes, by providing comprehensive medical care and intensive social support. It also promises to save Medicare and Medicaid millions of dollars by keeping those people out of nursing homes.

For decades, though, the program has failed to catch on, with only 40,000 people enrolled as of January of this year.

“PACE is still a secret in the minds of the public,” Andy Slavitt, Medicare’s acting administrator, said at the National PACE Association meeting in April. The challenge, he said, was to make PACE “a clear part of the solution.”

Several private equity firms, venture capitalists and Silicon Valley entrepreneurs have jumped into the niche. F-Prime Capital Partners, a former Fidelity Biosciences group, provided seed funding for a PACE-related startup, as have well-regarded angel investors like Amir Dan Rubin, the former Stanford Health Care president, and Michael Zubkoff, a Dartmouth health care economist.

And no company has moved with more tenacity than InnovAge. Last year, the company overcame protests from watchdog groups to convert from a nonprofit organization to a for-profit business in Colorado. And in May, InnovAge received $196 million in backing — the largest investment in a PACE business since the rule change was made — from Welsh, Carson, Anderson & Stowe, a private equity firm with $10 billion in assets under management.

Pedestrians are mirrored in a shopping window. (Ralph Orlowski/Getty Images)

“For years we were pariahs, and no one wanted anything to do with us,” said Julie Reiskin, executive director of the Colorado Cross-Disability Coalition, a nonprofit group that advocates for people with disabilities, many of whom are eligible for PACE.

Even the program’s supporters acknowledge that the movement needs fresh momentum. But they worry that commercial operators will tarnish their image in the same way many for-profits eroded trust in hospice care and nursing homes.

Three decades ago, after Congress authorized Medicare to pay for hospice care, commercial operators displaced the religious and community groups that had championed the movement. As recently as 2014, government inspectors found that for-profit hospice companies cherry-picked patients and stinted on care.

In addition, elderly patients with dementia and chronic ailments have frequently been targets of abuse and neglect at nursing homes, something advocates for the elderly say is correlated with the increased commercialization of that industry.

“I’m not wild about every knucklehead running around trying to do PACE,” said Thomas Scully, former Medicare administrator under President George W. Bush. “I would rather keep it below the radar.”

Not Quite Able

Early last year, Malveaux was drowning. She lived alone in a tidy red-brick home in a leafy Denver neighborhood that she paid for by working shifts at a Samsonite luggage factory, now closed.

Laundry piled up. Bills went unpaid. Doors were left unlocked. Pans sometimes burned on the stove as her memory failed.

“I had lost my mind,” she recalled, sitting on her couch in a pink velour robe. “I couldn’t keep up my house.”

For Americans who find themselves in this situation, the next stop is often a traditional nursing home. Malveaux’s son took her instead to visit an InnovAge day center.

The $9 million building south of downtown Denver is designed to calm people with dementia. It has subdued lighting and winding hallways that encircle the first floor like a running track and discourage “exit-seeking behaviors,” where patients search for ways out of a building.

For the frightened Malveaux, it seemed like paradise: a flower garden, a beauty salon and day trips to casinos and candy factories. And, most importantly, it had a team of doctors, nurses, psychiatrists, dentists, physical therapists, nutritionists, home health aides and social workers whose purpose was to help her live safely in her beloved brick home.

After joining the center in June 2015, Malveaux began seeing a psychiatrist and went on medication for depression. A social worker coached her grandson, Jermaine Malveaux, on how to care for someone with dementia. Three days a week, an InnovAge van picks up Malveaux at home and takes her to the center to share lunch with other older adults and try her luck at bingo and ceramics.

“I make friends easily,” she said with a smile. “And the guys flirt with me.”

The InnovAge center, like other PACE facilities, is inspired by Britain’s much-lauded Day Hospitals, outpatient health care facilities that arose in the 1950s that became a hub of daily life for many older people. In the United States, the earliest incarnation of PACE was started in San Francisco in 1971 by a group of Asian and Italian immigrant families seeking alternatives to the American nursing home.

Federal health officials allowed the group, called On Lok — Cantonese for “peaceful, happy abode” — to test what was then a novel and prophetic approach to health care financing. Instead of physicians billing Medicare each time they treated a patient, the government would pay a fixed amount to the center for each member. On Lok would assume the financial risk, similar to an insurance company. In 1990, Medicare officially sanctioned the model.

In exchange for a capped monthly payment from Medicare and Medicaid, PACE staff members arrange and pay for all of a patient’s doctors’ visits, medications, rehabilitation and hospitalizations. At the same time, they are supposed to pay attention to the patient’s daily needs — meals, bathing, housekeeping and transportation to day centers, where older people can ward off isolation and cognitive decline by socializing. (Studies have found that the intensive caretaking reduces costly hospital stays.)

Comparing the cost effectiveness of PACE against nursing homes is difficult, partly because state Medicaid agencies pay a variety of rates. But all the states are required to keep their rates below what they would pay for nursing home care. In Colorado, for example, that amounts to 7 percent less per patient.

On average, Medicare and Medicaid pay PACE providers $76,728 a person a year, about $5,500 less than the average cost of a nursing home. And the money going to PACE covers the all of the person’s health and social needs, unlike nursing home care, which doesn’t include hospitalizations and other expensive medical care.

The flat government payment pushes the organizations to invest in maintaining a patient’s health and safety to avoid big hospital bills. Dentistry — excluded from traditional Medicare coverage — is a crucial focus: Programs invest heavily to fix broken teeth and dentures to avoid costly infections or poor nutrition that can cause cascading health problems.

Providers are also generous with rehabilitation, setting few limits on training sessions that strengthen injured muscles and sturdy patients against falls.

“If you’re neglecting these patients, the odds they’ll call an ambulance and go to the hospital and spend a week there because they’re really sick is pretty high, and that all comes out of the payment,” said Bob Kocher, a former senior health care adviser to President Barack Obama.

Profits are in no way guaranteed, though. The centers still face major financial risk — it just takes a few patients with serious medical conditions to upend the books.

Dan Gray, a PACE financing consultant at Continuum Development Services, said too many trips to the emergency room or an expensive hospital stay can flip fortunes. One organization he advises had $300,000 in hospital medical claims in a month that he refers to as “Black August.”

“I had a nervous twitch,” he said.

High-Tech vs. High-Touch

In January, at the health care industry’s leading matchmaking event, the J.P. Morgan Healthcare Conference in San Francisco, word quickly spread that PACE programs could save states and the federal government up to 20 percent a patient. And suddenly, the program became one of the hottest topics of discussion.

“Every other conversation was, ‘What do you think we should do with PACE?’” said Bill Pomeranz, a managing director at Cain Brothers, who helped finance the nation’s first PACE program in the 1970s.

The message appeared to travel down Highway 101 as well, to the heart of the technology industry. At least eight startups have circulated PACE-related pitches to Silicon Valley venture capital firms, hoping to tap into new capital and create technology-enabled versions of the program.

The interest of the tech industry is so far only nascent. But the possibility that Silicon Valley, notoriously aggressive and extremely deep-pocketed, could play a significant role in PACE underscores the changes that may lie ahead.

Building a center requires medical offices, rehabilitation equipment, food service and fleets of handicapped-accessible vans. On average, it takes up to $12 million just to get it off the ground. That is a lot of money for most nonprofits but relatively little in the technology world. Opening new centers may become less of a hurdle.

The tech industry and nonprofit world are driven by different impulses. The early centers were closely tied to local cultures, making them difficult to replicate. An aversion to aggressive marketing among the center’s leaders didn’t help, either. Tech likes to move as fast as possible.

“PACE reminds me of religious orthodoxy,” said Mr. Pomeranz, who said he had affection for the program. The movement’s leaders come from the world of public health and have a “social work mentality,” he added.

The pitches circulating among investors envision technology-enabled programs that would rely, in part, on video visits and sensors. Some studies have found that telemedicine can help patients better control certain chronic conditions and reduce health care spending. But those technologies are largely untested in geriatric care.

“The entrepreneurs coming into this space all believe there are much lower-cost ways to check on patients every day than driving them all to one building,” said Mr. Kocher, who is now a partner at the venture capital firm Venrock, which invests in health care companies.

These sorts of pitches, while promising, have not been universally welcomed. They’ve even been used as evidence that opening PACE up to for-profit companies might lead to unwanted consequences.

Veteran PACE providers, for example, are skeptical of virtual medicine’s benefits to seniors, especially those with dementia.

“Socialization goes a long way to improve the health of the participants we serve,” said Kelly Hopkins, president of Trinity Health PACE, a nonprofit health system that operates PACE centers in eight states. “It’s naïve to think you can do it virtually.”

Diane Schoenfeld (left) and her aunt, Lillie Manger, look at old family photos in the dining room of Berkeley’s Chaparral House, the nursing home Manger lives in. (Rachel Dornhelm/KQED)

Supporters of the change say the necessary safeguards are in place. The for-profit centers were approved, to little fanfare, after the Department of Health and Human Services submitted the results of a pilot study to Congress in June 2015. The demonstration project, in Pennsylvania, showed no difference in quality of care and costs between nonprofit PACE providers and a for-profit allowed to operate there.

The Centers for Medicare and Medicaid Services has vowed to closely track the performance of all PACE operators by measuring emergency room use, falls and vaccination rates, among other metrics. The National PACE Association, a policy and lobbying group, is also considering peer-reviewed accreditation to help safeguard the program. Oversight is now largely left to state Medicaid agencies.

Maureen Hewitt, InnovAge’s chief executive, said, “At the end of the day, we’re held to the same quality and care standards.”

Dr. Si France, a founder of WelbeHealth, an early-stage company based in Menlo Park, Calif., says startups can use technology to improve clinical communication, help caregivers make treatment decisions and monitor patients at home or in a hospital. But he insists even a high-tech PACE program cannot veer from its origins.

“It’s not a way to get rich or generate outsize returns,” said Dr. France, the former chief executive of GoHealth, a chain of urgent care centers acquired by TPG Capital, a private equity firm. “We think this is an arena for missionaries, not mercenaries.”

Will Money Change Things?

Families enrolled in InnovAge’s PACE program in Denver appeared to be unaware of its conversion into a for-profit enterprise. The company did not announce the change directly to its participants, but notified a patient advisory group.

Kathy Baron, 68, who lives in subsidized senior housing, was left disabled by breast cancer and debilitating nerve pain. Her daughter, Leah van Zelm, struggled to take care of her. So Baron, fearful she would be deemed unfit to stay in her apartment, signed up for InnovAge’s program.

“I would rather be dead than go into a nursing home,” Baron said.

She says InnovAge has been generous with services, echoing interviews with other patients. Each week, an InnovAge housekeeper changes the sheets on her bed, launders her clothes and cleans her apartment, a service provided to those unable to tidy their own homes. The few times her requests for special equipment or services were denied, Baron appealed and won.

But she worries new investors will skimp on what outsiders might view as unwarranted services. The company’s commercials, promising “Life on Your Terms” and voiced by the actress Susan Sarandon, have reinforced those concerns.

It’s a concern echoed by Malveaux’s family. “Anytime you involve money,” said Malveaux’s grandson Jermaine, “there’s always the concern for greed, especially with the elderly.”

At least in the near future, the number of companies getting into PACE programs will be limited. Most states currently cap enrollment in PACE centers. And each state — as Colorado did, opening the window for InnovAge — likely needs to amend its law to allow the for-profit companies. So far, it appears only California has done so.

Yet there is a growing realization among longtime PACE providers that new competition looms.

In a newsletter to the generally placid PACE community, one adviser warned that providers who failed to become bigger would face new entrants who “will find a way to meet the needs of persons in your community.”

Those needs will only grow as the adult children of baby boomers face difficult decisions about how to care for their parents.

In the meantime, for people like Van Zelm, the anxiety that once pervaded her daily life has diminished.

“When she’s stable,” Van Zelm said of her mother, “my daily life stress is reduced.”

]]>https://ww2.kqed.org/stateofhealth/2016/08/24/worries-as-the-for-profit-world-moves-into-elder-care/feed/0228587Proposed California Budget Cuts Threaten Adult Day Health CareRegistered nurse JoAnn Brand examines Sham Tavakol.Gaining Respectful Health Care, a Struggle for Transgender Eldershttps://ww2.kqed.org/stateofhealth/2014/06/09/gaining-respectful-health-care-a-struggle-for-transgender-elders/
https://ww2.kqed.org/stateofhealth/2014/06/09/gaining-respectful-health-care-a-struggle-for-transgender-elders/#respondMon, 09 Jun 2014 13:57:00 +0000http://blogs.kqed.org/stateofhealth/?p=19352Pamela Howland, 76, moved back to San Francisco in part because of the discrimination she faced in Arizona hospitals because she is transgender. (Ryder Diaz/KQED)

Editor’s Note: In the coming years, California’s senior population is expected to grow more than twice as fast as the total population. As part of our occasional series on health calledVital Signs, we’re spending the month focusing on older adults. Today we meet 76-year-old Pamela Howland. When she retired, Howland decided she could finally live as a woman after spending her entire life as a man. But being a transgender senior has come with many challenges, including discrimination, even in health care settings..

By Pamela Howland

I had decided that the years I had left, I wanted to live the way I wanted to live. It was a shame that I had to make the change because it would have been so much easier to continue living as a male rather than encounter the difficulties of living as a transgender female that doesn’t pass as female.

I had been in Arizona about two years, when I had a [abdominal] surgery and the surgery damaged a very key nerve in controlling my gastrointestinal system.

I spent on and off three months in the hospital, and I had some very, very terrible treatment both by nurses and doctors.

They didn’t approve of me taking estrogen, so they weren’t going to go out of their way or do anything to help me take that estrogen. I said, I have to take it and not only that, if I don’t take it I’m going to go through withdrawal.They just assume say, ‘Let him suffer.’

That’s another thing that comes up continually. ‘Sir.’ I’m called “sir” rather than “ma’am.”

You’re trapped. And not only that, you’re very vulnerable because you’re in the hospital for a reason: you’re sick.

As I get older, there are going to be other reasons why I’m hospitalized. It happens to everyone.

The only way I could be confident about the medical system was to come back to San Francisco. So, I left a home that I had planned on living in the rest of my life — and an area I planned on living the rest of my life — purely for medical support.

I think the absolutely most important thing for anyone is to have an advocate, someone who can help you through whatever medical crisis or medical difficultly you’re having. If you’re not being heard, if they’re not paying attention to you, your advocate can do something for you because you’re not in a condition where you can do anything about it.

]]>https://ww2.kqed.org/stateofhealth/2014/06/09/gaining-respectful-health-care-a-struggle-for-transgender-elders/feed/019352IMG_0237Living With Grace in a Nursing Homehttps://ww2.kqed.org/stateofhealth/2013/12/30/living-with-grace-in-a-nursing-home/
https://ww2.kqed.org/stateofhealth/2013/12/30/living-with-grace-in-a-nursing-home/#respondMon, 30 Dec 2013 17:05:28 +0000http://blogs.kqed.org/stateofhealth/?p=16954Editor’s Note: Eighty-three-year-old Phyllis Donner Wolf figured she would live on her own until the end of her life and die peacefully in her sleep. But last spring, she fell and broke her neck, leaving her paralyzed from the chest down. She went from living independently in her apartment in Palo Alto to a nursing facility in San Francisco called the Jewish Home. As part of our ongoing series of first-person health profiles called “What’s Your Story?” we talk to Wolf about what it takes to live a life of grace in a nursing home.

By Phyllis Donner Wolf

I was very active. I did yoga. I did yoga for 40 years. I was in an exercise class that met every morning at quarter to 8. I drove the car for friends to go to the symphony in the city. I was the one who took someone’s walker and put it in the trunk. So when I fell it was unbelievable. I didn’t dream I would wind up in a wheelchair.

I stood up in the middle of the night, which I often would just walk to the bathroom, and this time when I stood up I found myself on the floor. I think I heard a crack, which meant that my neck and spine, the bones just were brittle and broke. And I knew I had done great damage because I could not move the lower part of me.

Institutional living means you put your body and yourself into someone else’s control. I was expected to have a shower at a certain time, and I was expected to go to bed at a certain time, I was expected to get up and get dressed at a certain time. And that’s still difficult. Especially when you’ve been so independent.

What I see here are people who are well taken care of; people who are very limited physically and mentally. My first shock at seeing the dining room with people who could not feed themselves or whose heads are down in their lap, was like, “How am I going to eat in here every night?”

You can choose to go in your bedroom, lock the door, never see people, mope, complain. Or you can just face life. I mean this is what’s happened to you, deal with it.

I just feel that it’s more fun to laugh and smile than to really weep over what’s taken place for me or for the other people. I’m going to make my fun. I’m going to make my laugh, my smile, I’m not going to let it get me down.

]]>https://ww2.kqed.org/stateofhealth/2013/12/30/living-with-grace-in-a-nursing-home/feed/016954PhyllisPhyllis Donner WolfLoneliness is Bad For the Elderlyhttps://ww2.kqed.org/stateofhealth/2012/06/21/loneliness-is-bad-for-the-elderly/
https://ww2.kqed.org/stateofhealth/2012/06/21/loneliness-is-bad-for-the-elderly/#commentsThu, 21 Jun 2012 21:05:48 +0000http://blogs.kqed.org/stateofhealth/?p=6647Continue reading Loneliness is Bad For the Elderly→]]>By Alvin TranThere is a 45% increased risk of death in people who are lonely compared to not lonely, according to a UCSF study. (Photo: Getty Images)

Do you feel left out? Isolated? Or lack companionship? Answer ‘yes’ to any of these questions and you may be at risk for adverse health outcomes, says Carla Perissinotto, MD, an Assistant Clinical Professor at UCSF.

Perissinotto’s latest study, which found a link between loneliness and serious health problems among the elderly, was the main topic of Wednesday’s Forum with Michael Krasny.

The study, published this week in the Archives of Internal Medicine, followed over 1,600 elderly individuals for six years. These individuals completed surveys that measured whether they felt left out, isolated, or lacked companionship — all of which are components of loneliness.

“We cannot continue to ignore the psychosocial distress that our patients are experiencing. It is, in fact, just as important as traditional medical risk factors.”

“We demonstrated that [loneliness] is also a risk factor for poor health outcomes, including death and multiple measures of functional decline,” said Perissinotto. “[There is a] 45 percent increased risk of death in people who are lonely compared to not lonely.”

Perissinotto says medical professionals also need to put more emphasis on the role of psychosocial distress on health. “We cannot continue to ignore the psychosocial distress that our patients are experiencing,” Perissinotto said. “It is, in fact, just as important as traditional medical risk factors.”

According to Perissinotto, medical schools currently emphasize the role of traditional medical risk factors such high blood pressure, cholesterol and obesity and pay less attention to factors such as social support and loneliness. “There needs to be a slight shift where we don’t ignore the traditional medical risk factors but we also incorporate things like loneliness into the general assessment of our patients,” Perissinotto urged.

On a positive note, Perissinotto does acknowledge the existence of health care programs that currently screen for loneliness among patients such as the Bay Area’s Institute on Aging. The institute’s Friendship Line is a phone service that reaches out to elderly individuals and offers a variety of services, including emotional support.

Karyn Skultety, the Director of Clinical and Community Services at the Institute on Aging and another guest on KQED’s Forum, cautions the idea of relying on screens alone. Screens are useful and helpful but should not replace the ability to ask clients questions, she said. “Nothing substitutes real good conversations with someone.”

The two guests also clarified a common misconception over the definition of loneliness itself. “Loneliness is the subjective feeling of isolation, not belonging, or lacking companionship,” said Perissinotto. About two-thirds of her study’s participants who were classified as lonely were married or living with a partner. Skultety added that loneliness is not based on the quantity of friendships, but on the quality and type of friendships.

Skultety added that society does not view careers involving care for the elderly as rewarding. She said this viewpoint is responsible for the current shortage of medical professionals available to work with older adults. “We haven’t done enough in terms of our spending and choices in our health care system,” she said.

“In our medical schools across the country, geriatrics education is not a focal point. It is not viewed as important,” Perissinotto added. “It is a huge detriment to our future physicians and adults in this country and abroad.”

Hundreds of thousands of people provide care – from cooking and cleaning to bathing and dressing – for adults with disabilities or long-term illnesses who receive benefits from Medi-Cal. As it turns out, those who get paid for this work may not be pulling in enough money to make ends meet.

Geoffrey Hoffman, a researcher at the Center and lead author of the report said, “These paid Medi-Cal caregivers have incomes that are quite low compared to other Californians, about half as much monthly household income.”

“This aging population [of caregivers] is going to lead to great burdens on the health care system.”

He continued, “A third of them do not have health insurance. A number of them live in poverty or near-poverty, and, among those, a third of them have what is called ‘food insecurity’ – not enough food to put on the table every month.”

At issue is the amount that Medi-Cal is paying these caregivers. Even if you add income from other jobs, they earn a little over $11 per hour on average — close to minimum wage, and about two-thirds of the median income in California — making it difficult for them to live on their earnings. Many believe that the value of the care they provide is much greater than what they earn, but monetary constraints have led California lawmakers to decrease financial support for these services.

In 2011, the state budget cut the Medi-Cal caregiver reimbursement program – In-Home Supportive Services – by 3.6 percent. State officials had also planned a 20 percent decrease in the number of hours a caregiver could work, but that cut has been blocked by a judge for now.

Hoffman worries these trends could affect the quality of care available to those who need assistance. “If the caregivers are having trouble putting food on their own table, then they’re not going to provide the type of care we want for our grandparents and our spouses in this state.

As these caregivers themselves begin to age, Hoffman said he is also concerned that those who are economically disadvantaged will end up costing the system more money later on, making it even more difficult for Medi-Cal and Medicare to stay solvent in years to come.

“This aging population [of caregivers] is going to lead to great burdens on the health care system. So the sooner we address the problem today, the better off we are for our older adults’ health … in the future.”

Back in the days when modern medicine started, around the turn of the 20th century, the practice of medicine was roughly divided into thirds: diagnosis, treatment and prognosis.

That’s what Alexander Smith, palliative care expert at the San Francisco VA Hospital, told me in an interview. He attributed the approach to the illustrious William Osler, one of the founding professors of Johns Hopkins Hospital, back in the late 19th century.

But things have changed since Dr. Osler ruled in Baltimore. “Prognosis has really waned,” Smith says. “Now in textbooks, there’s just a few lines. The focus is on diagnosis and treatment.”

Smith and a handful of colleagues are trying to refocus doctors and other clinicians on prognosis in older patients. But it looks like he has a long way to go. In today’s Journal of the American Medical Association, Smith and his colleagues assess the efficacy of 16 different ways to measure prognosis. Unfortunately, the authors find that all of them are lacking in one way or another. Failure to consider prognosis is a problem, they argue, because it can lead to poor care.

“Prognosis is a critically important piece of information for decision-making in the elderly,” Smith said. “For most preventive measures, the harms occur up front, but the benefits don’t accrue for years.”

One case in point is the colonoscopy. “There’s an immediate risk of intestinal perforation. It sounds awful and it is. While uncommon, it’s horrific when it happens.” While colonoscopies are great at finding very early colon cancers, that’s what they are, very early. This is where overall prognosis comes in. As people get older, their likelihood of dying with and not of a particular cancer goes up, so why subject patients to screening tests?

This isn’t a question just of a patient’s age, which is what doctors call a “blunt instrument.” A better way to measure prognosis, Smith said, would be to add in other factors, “like what other medical conditions a patient has, what functional status a patient has, like walking, bathing, calculating checkbooks, what cognitive impairment they have.”

Smith and his colleagues have taken the 16 current imperfect tools that measure prognosis and put them together in a new website, www.eprognosis.org, specifically for doctors and other health care workers. The goal is for doctors to use the individual tools and then rate them on usefulness. But doctors should use the information as one tool, in combination with discussions with patients and their patients’ preferences.

Still, Smith stressed that doctors tend to be optimistic when estimating prognosis, and the better they know the patient, the more optimistic they become.

“If a patient has the information, then patients and doctors are more likely to make choices that are sensible. They are less likely to pursue tests and treatments that are likely to be harmful and they can shift priorities to other things like maintaining mobility and independence.”